Medical Professional Publications

A Feeding Protocol for Newborn Congenital Heart Disease Patients

Columbus, OH — February 2017

Congenital heart disease literature has minimal guidance for when to start enteral feeds and how best to advance them; inconsistency even among a single institution’s providers can be expected. So a group of clinician-researchers in The Heart Center at Nationwide Children’s Hospital developed a feeding protocol to reduce newborn feeding variation in its Cardiothoracic Intensive Care Unit (CTICU).

The protocol, as reported in two recently published studies, contributed to a general decreased length of stay and, in a subset of patients undergoing the hybrid procedure, a 50 percent reduction in the incidence of necrotizing enterocolitis (NEC). While the reduction in NEC did not reach statistical significance because of sample size, the authors consider it to be of clinical significance.

“We made the guidelines simple and conservative based on our group experience and what was available in the literature,” says Janet Simsic, MD, an attending cardiologist in The Heart Center and medical director of the CTICU. “Another institution may decide on different guidelines that are less conservative. That would not be wrong. For us, the exact guidelines were less important than having guidelines at all. Consistency in care makes a difference.”

Dr. Simsic, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine, is lead author of the study in Congenital Heart Disease describing the protocol and co-author of the study in Pediatric Cardiology reporting the results among babies undergoing the hybrid procedure.

There actually were two protocols -- one for extubated babies, and one for intubated babies or those on noninvasive positive pressure ventilation (NiPPV). Assuming the maintenance of baseline criteria (such as arterial pH < 7.35 and venous pH < 7.30), the protocols were, in brief:

Extubated babies. PO ad lib on Day 1 with unfortified breast milk or formula for 24 hours (limiting feeding sessions to 30 minutes, and limiting babies with umbilical artery catheters to 9 mL/kg/feed). If the intake is adequate, based on age and weight, continue PO ad lib. If intake is inadequate, transition to PO or nasogastic gavage feeds, starting at 3 mL/kg/feed every three hours, advancing 3 mL/kg/feed every 24 hours with a goal of 18 mL/kg/feed.

Intubated babies or those on NiPPV. Trophic feeds of unfortified breast milk or formula start through nasogastric or nasojejunal tube at 1 mL/kg/hour for 24 hours. If trophic feeds tolerated, advance by 1 mL/kg/hour every 24 hours with a goal of 6 mL/kg/hour for babies without an umbilical artery catheter or 3 mL/kg/hour for those with an umbilical artery catheter.

The most difficult part of instituting the protocol was ordering it, says Dr. Simsic. An ongoing update of Nationwide Children’s electronic medical record system made creating a new order set impossible for a time, leading to some communication difficulties between physicians and nurses. Laminated bedside cards detailing the protocol, the inclusion of Heart Center dieticians in rounds and the eventual creation of an order set allowed protocol adherence to reach 100 percent.

“This ultimately resulted in less confusion for everyone,” says Dr. Simsic. “Nurse practitioners and bedside nurses could be confident that week to week, the strategy would be consistent no matter which physician was on service. Less confusion is always better.”

References:

Simsic JM, Carpenito KR, Kirchner K, Peters S, Miller-Tate H, Joy B, Galantowicz M. Reducing variation in feeding newborns with congenital heart disease. Congenital Heart Disease. 2016 Nov 16.  [Epub ahead of print]

Carpenito KR, Prusinski R, Kirchner K, Simsic J, Miao Y, Luce W, Cheatham JP, Galantowicz M, Backes CH, Cua CL. Results of a feeding protocol in patients undergoing the hybrid procedure. Pediatric Cardiology. 2016 Jun;37(5):852-9.

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